Civil War Washington

CASE 98.—Private D. Rapp, Co. K, 7th Indiana, aged 20 years, was wounded at Robinson's Creek, November 30, 1863. He was admitted to the field hospital of the 1st division, First Corps, where Surgeon G. W. Metcalf, 76th New York, noted: "Gunshot wound of left thigh." On December 6th, the wounded man was transferred to Douglas Hospital, Washington. Three days afterwards he was operated on by Assistant Surgeon W. Thomson, U. S. A., who furnished the following detailed report of the case: "He was a well developed and very muscular man and had been apparently in good health. At the moment of injury he was retreating, and was struck by a bullet on the posterior aspect of the left thigh a short distance below the gluteal fold, which passed through the limb to the inside of the bone, divided both femoral artery and vein, and made its exit three and a half inches below Poupart's ligament, at the point of election in ligating the femoral in Scarpa's space. There was profuse hæmorrhage at the time of injury, and an immediate want of sensibility in the leg and foot. When examined on the 7th of December, the whole limb was found warm and the collateral circulation had been established; but there was no pulsation in either of the tibial arteries. At the superior margin of the wound of exit there was a small tense swelling, which pulsated synchronously with the systole of the heart. An aneurismal​ thrill, resembling the loud purring of a cat, was distinctly felt, extending along the course of the vessels into the pelvis, but not communicating laterally. The little finger was introduced into the wound at the time of the operation, and the pulsation and thrill were found to be closely localized and confined to the divided ends of the femoral vessels. There was no extensive effusion of blood into the tissues of the thigh, and hence this was not in the strict surgical sense of the word a traumatic aneurism​. It was concluded that the sac was composed only of the sheath, which had been united by inflammation after the division and retraction of its vessels, and had then been some what distended after the heart had regained its force. It was also suggested by Surgeon Lidell, who kindly saw the case with me, that there was a free communication between the divided artery and vein in this sac which permitted the arterial blood to return freely by the vein, as evinced by the pulsation communicating with such force backward toward the heart in the line of the vessels. It was unmistakable that there existed a wound of the femoral artery sufficient to cause its obliteration, that an aneurism​ was being developed at the divided proximal extremity, and that the proper surgical procedure would be to secure the ends of the vessel at the point of the injury. It was determined to emulate the example of Mr. Syme, to lay open boldly the sac by a free incision and search for and secure the bleeding orifices. It was hoped that the profunda had escaped injury and every precaution was to be used to secure the femoral below its origin. A small hæmorrhage on December 9th rendered immediate interference necessary, and the following operation was then done with the assistance of Surgeon Lidell and the medical officers of the hospital. After the patient had been fully etherized and the femoral artery thoroughly compressed on the pubes by the thumb of a reliable assistant, as evinced by the loss of pulsation in the tumor, an incision four inches in length was made through the skin and fasciæ, immediately over the tumor and including the gunshot wound, in a line parallel with the sartorius. A second incision was now made into the tumor, which was dilated instantly by the finger to the size of the first. Distal hæmorrhage was anticipated, and it caused but little surprise when a most profuse dark colored torrent poured out from the incision. The lower angle of the incision was rapidly searched in vain for the source of the hæmorrhage, and it was feared that it might come from the dark softened depth of the track of the ball. No pressure on the artery had the least controlling effect upon it. The removal of the sponge was followed instantly by a boiling dark torrent of venous blood, which so quickly filled the cavity as to prevent any examination. So profuse and uncontrollable was the flow that visions of ligating the external iliac were vividly presented to the mind. When the flow was found to arise from the superior angle of the incision numerous and ineffectual efforts were made to secure the vessel, but the parts were so hardened by local inflammation that the forceps glided over them as it would over a cartilaginous surface. This point, from whence the dark blood seemed to flow, was finally compressed by the point of the left index finger, and by means of the nail of the small finger of the right hand a vessel was isolated, a ligature passed around it with an aneurism​ needle, and this hæmorrhage, most embarrassing because uncontrolled by pressure, was finally suppressed. The first ligature was applied at the superior angle of the incision to the proximal extremity of the divided femoral vein, from which this unexpected and most annoying artery and vein, hæmorrhage escaped by regurgitation from the saphena​. The blood found its way into the limb by means of arteries arising from the iliac above the point compressed, was finding its way back by the saphena​, enlarged to compensate for the occlusion of the femoral, was poured into the femoral a short distance above its divided proximal extremity, and then regurgitated through the stump of the femoral into the superior angle of the incision. The proximal end of the femoral artery, from which a crimson tide escaped on relieving the pressure slightly, was now easily found, and this was ligated. The wound was now thoroughly cleansed of all clots of blood. The femoral artery and vein, denuded of their sheath for a distance of two inches, were clearly seen at the bottom of the wound, their divided extremities having become adherent to the neighboring tissues during the inflammatory action of the previous ten days. As a precautionary measure a ligature was cast around the femoral artery at the lower angle of the wound, and some little difficulty was experienced in discriminating between the artery and vein, owing to the fact that from ten days disuse the vein in becoming an impervious cord had become similar in size, color, and consistency to the artery. A small orifice was observed in the vein near its distal extremity, and from this occurred a free black flow on moving the limb. This was also included in a ligature. The wound was now closed by one or two sutures and the patient placed in his bed. A brief recapitulation may give clearness to the above account. The first vessel tied was, therefore, the proximal extremity of the femoral vein near the entrance of the saphena​; the second, the femoral artery a short distance below the origin of the profunda, both at the superior angle of the incision; the third, the femoral artery at the lower angle of the incision and two inches from its distal extremity; the fourth, the femoral vein near its distal extremity at the centre of the incision, and to control a flow from an incision through its coats, which may have been made accidentally. The profunda had not been seen, and it was hoped that it would suffice to keep up the circulation. No important arterial channels had been interfered with by the operation, and a successful issue might be expected. The man was stimulated, took morphia, and his leg was covered closely in bed with blankets to preserve the animal warmth. This man had lost blood freely at the time of the injury; he had been subjected to a very long and fatiguing transport in ambulances and cars before reaching the hospital, and for seven days his food had not been as good or sufficient as might have been desired for one about to undergo such an operation. He was pallid and haggard looking, and iron, nutrients, and stimulants were freely ordered. There was great pain and restlessness during the ensuing night, and large quantities of morphia were required to procure sleep. December 10th, no interference with the circulation; leg and foot both warm. The whole limb is swollen, and bloody serum escapes freely at the point of the injury. December 12th, the restlessness has been the most marked symptom, caused seemingly by constant and severe but indescribable pain in the limb. The pulse is 120, the countenance pale and haggard, the tongue dry and coated, and the general symptoms indicate great nervous prostration. Large quantities of morphia have been found requisite. The whole limb and foot are much swollen and œdematous. On the evening unmistakable signs of sphacelus appeared, the foot became cold, and a hue of purple discoloration was observed as high up as the ankle. The neuralgic pain and restlessness still continued. On December 13th, all the symptoms were worse. The discoloration, the dark purple hue of gangrene, extended rapidly upward, particularly on the inside of the limb. The whole thigh became crepitant, the pulse more rapid and feeble. He became more and more depressed, and finally died at 12 o'clock at night. These final scenes all surgeons can imagine. The post-mortem revealed nothing interesting in the great cavities. The whole thigh and leg were found gangrenous as far as the point of the injury. The vessels were dissected, spread upon a board, and a most faithful picture was made of them by the artist under Dr. Brinton's direction. Only the proximal extremities of the vessels were found in the softened gangrenous mass; but they threw light upon the history of the case. The artery was divided below the origin of the profunda, which was uninjured, but not enlarged, as one would expect if the whole force of the circulation had been directed toward it by the obliteration of the main artery. In ten days the profunda should here have been as large as the femoral, if all the blood brought to the divided femoral had been seeking a passage through its calibre. Its undilated condition gives color to the idea that most of the blood brought to the divided femoral extremity found its way quickly back by the divided femoral vein; that the pressure was thus relieved, and that the profunda received only its usual supply of blood. That the limb was nourished by a collateral circulation, arising above the brim of the pelvis, is clear from the fact that no pressure on the external iliac would restrain the flow of blood from the saphena​ through the femoral vein. The saphena​ vein is normal, and its relation with the femoral indicates how easily the regurgitating hæmorrhage was caused, as no valves are there to prevent it. For several days—from the 9th to the 12th—there were no signs of an interference with the circulation, but at that time gangrene appeared and spread with great rapidity. This may have been due to the recent phlebitis of the profunda vein, which is now filled with a pink firm coagulum. The irritation caused by the operation, or due to the passage of the ball, may have induced the inflammation of this vein, now so vital to the support of the circulation. This seems to have been a wound of an artery, resulting in an aneurism​ the sac of which was composed of the re-united sheaths and enlarged probably by some dissection upward, in which a free passage of blood took place from the artery to the vein. No question as to the propriety of the operation now exists in my mind, since, as the sequel shows, no digital compression over the femoral would have sufficed to prevent or control a secondary hæmorrhage." The two specimens were contributed by the operator, Dr. William Thomson (see FIG. 19). The case is cited by Dr. Lidell¹.

¹ LIDELL (J. A.). On the Wounds of Blood-Vessels, Traumatic Hæmorrhage, Traumatic Aneurism​, and Traumatic Gangrene, in Surgical Memoirs of the War of the Rebellion, collected and published by the United States Sanitary Commission, 1870, Vol. I (Surgical), p. 143.

FIG. 19.—Ligation of femoral artery and vein. Specs. 2249, 2250.